Analysis of both the subjective and objective data

Reference no: EM133396155

You are an RPN on a Surgical Unit. You are caring for Mr. Johnson an 84-year-old male who was brought in to the Emergency department for a Hip Pain after falling on ice. X-ray shows he has Right Hip Fracture. He has a history of Hypertension, Dementia, Bipolar Depression and Asthma. He is a DNR (Do not Resuscitate) and has no known allergies. Mr. Johnson has been admitted for possible surgery and pain management. He was given morphine IV at 1800hrs and is not complaining of pain and. He has a coccyx dressing which is intact. He is receiving Normal Saline in his right forearm. Vital signs are BP 140/70, P-78, Temp. 36.5, Resp. 20 Oxygen saturation 98% on 2/Litres Nasal Prong. His daughter is at the bedside and requesting to see a doctor. The nurse called the Dr. Stanberg who is the admitting doctor and will see Mr. Johnson later today. The daughter states they are unable to cope at home and is requesting that her dad be transferred to a nursing home closer to home.

PART: 2

Please "complete" a SOAP Note. You must include a date and time in your documentation using the 24-hour clock. Your designation to sign off the documentation is SCPNS(Seneca College Practical Nursing Student). (15 Marks)

You are the nurse caring for Mrs. Thompson and you started your shift at 0730 and your shift will end at 1530. You have completed an assessment on Mrs. Thompson at 0800 and below are your finding:

Subjective: what Mrs. Thompson the data given to you by Mrs. Thompson

Objective: The information you received(observed and assessed eg. Vital signs etc)

Analysis: An analysis of both the subjective and objective data

P: Plan (put a plan in place based on you data analysis)

Assessment:

Admitting Diagnosis: Chest Pain

Past Medical History: Hypertension, Coronary Artery Disease, Type 2 Diabetes

Code Status: Full Code

Neurological System: Alert, confused, fatigue, hitting the nurse ever time they try to provide care.

Hearing: Uses hearing Aid

Eyes: Wears Glasses, legally blind

Respiratory: Decrease air entry to lung bases

Cardiovascular: Irregular heart sound. Legs swollen

Gastrointestinal: Last Bowel movement 2 days ago. Decrease bowel sound to right upper and left lower quadrant. Having nausea and vomiting for 2 dats. Lost 5 pounds in 2 weeks. Decrease appetite. Needs assistance with meal

Genourinary: Foul smelling concentrated urine

Musculoskeletal: Tremors, joint pain, generalized weakness

Sleep and rest: sleep 6 hours at night takes sleeping pill at home

Integumentary: Normal, warm to touch, bruising to right arm and left shoulder, dull hair, nails brittle

Mobility: Able to ambulate, unsteady on feet, needs assistance to get to the washroom, uses a walker

Pain: Joint pain 5/10

Falls: Has had 3 falls in the past month

PART: 3

Please complete a Narrative Note on Mrs. Thompson. You must include a date and time in your documentation using the 24-hour clock. Your designation to sign off the documentation is SCPNS (Seneca College Practical Nursing Student).

Reference no: EM133396155

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